Pennsylvania Department of Health
CATHEDRAL VILLAGE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CATHEDRAL VILLAGE
Inspection Results For:

There are 110 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


CATHEDRAL VILLAGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated survey in response to a reportable event, completed on October 27, 2025, it was determined that Cathedral Village was not in compliance with the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on clinical record review, interviews with staff and facility documentation, it was determined that the facility failed to implement the comprehensive care plan related to the resident transfer via mechanical lift for one of six residents reviewed. (Resident CL1)

Findings include:

Review of the report for an investigation of alleged neglect for Resident CL1 revealed that on September 2, 2025 two nursing assistants, Employees E10 and E11, transferred Resident CL1 by stand pivot method instead of using the mechanical lift as care planned. The nursing staff noted that Resident CL1 sustained an opened area to the right shin, when the leg hit the side of the bed during the stand pivot transfer from the wheel chair to the bed.

Clinical record review for Resident CL1 revealed that the licensed nurse described the skin tear/puncture to the right shin as bleeding. The nurse obtained an order from the physician for Resident CL1 to treat the right shin wound with normal saline and a foam dressing on September 2, 2025.

Clinical record review revealed that the two nursing assistants failed to follow the comprehensive care plan that had been developed for Resident CL1 to ensure safe transfers. The care plan indicated that Resident CL1 required the use of a mechanical lift for transfers from the wheel chair to bed/bed to wheel chair.

Interview with the registered nurse, Employee E5, at 10:30 a.m., on October 27, 2025 confirmed that Resident CL1 was care planned for safe transfers from the wheel chair to the bed/bed to the wheelchair using the mechanical lift.

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services

28 PA. Code 211.5(f)(vii)(ix) Medical records

Plan of Correction - To be completed: 11/19/2025

Resident CL1 was assessed, treatment ordered to lower right shin. No other injuries were noted. Therapy evaluation was initiated. Resident deemed a one person assist. Care plan updated and linked to Point of Care for caregivers to view.
A full house audit on current residents who are mechanical lifts was conducted to ensure mechanical list transfer status is appropriate, noted in-care plan and linked to Point of Care for caregivers to view. Variances will be addressed.
The Director of nursing or designee will reeducate the Nursing Staff on the Transfer policy and the importance of following the care plan.
The Director of Nursing or Designee will complete a random audit on 3 residents weekly X 4 weeks and then monthly X2 months who are mechanical lifts to ensure transfer care plans are accurate and are properly linked to Point of Care for the caregiver to view. Audits will be forwarded to Quality Assurance for review and any recommendations as needed.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement